Addison County Community Health Needs Assessment 2018 - Conducted by: Addison County Community Health Action Team (CHAT) Steering Committee

 
Addison County Community Health Needs Assessment 2018 - Conducted by: Addison County Community Health Action Team (CHAT) Steering Committee
Addison County
        Community Health Needs Assessment
                                   2018

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Conducted by:
Addison County Community Health Action Team (CHAT) Steering Committee

    1                                                              July 17, 2018
Addison County Community Health Needs Assessment 2018 - Conducted by: Addison County Community Health Action Team (CHAT) Steering Committee
Table of Contents

Executive Summary                                                            page 3
Overview of our Community                                                    page 5
Organizing to Address the Health and Wellbeing of Addison County Residents   page 7
Review of Addison County data                                                page 10
Community Survey Findings                                                    page 12
Implementation Plan                                                          page 14
References                                                                   page 18
Appendix A: Community Health Action Team Charter                             page 20
Appendix B: Addison County Data meeting breakout session notes               page 28
Appendix C: Prevention Change Packets Priority Areas for Addison County      page 31
Appendix D: Community Survey Summary Charts                                  page 47
Appendix E: Community Survey Questions                                       page 52
Appendix F: CHAT Housing Subcommittee Housing Proposal                       page 61

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Addison County Community Health Needs Assessment 2018 - Conducted by: Addison County Community Health Action Team (CHAT) Steering Committee
Executive Summary
Since our last Community Health Needs Assessment, Addison County’s healthcare and human
service partners have taken many steps to improve the health and well-being our community.
Our 2018 Community Health Needs Assessment describes this beautiful place we call home
and how we, as community partners, have organized ourselves differently to be more effective.
This report also shares various data sources we reviewed and includes highlights of a
community survey we conducted in the spring of 2018.
Below are some of the data sources we reviewed as well as steps we have taken to solicit input
on the top concerns and priorities for our community:
In December 2016, the Community Health Action Team (CHAT) hosted a strategic planning
session with a range of partners. At that meeting, we prioritized the following needs in our
community:
   •       Providing more family supports and community-wide programming & education
   •       Improving care coordination
   •       Increasing access to opioid treatment and affordable housing
We reviewed many Addison County data sources from across the lifespan during our first CHAT
data meeting in December 2017. The most significant discovery from that meeting was
identifying a lack of resilience among Addison County’s school-age children.
Over the winter of 2018, we reviewed Addison County data for the health measures included in
the Vermont Department of Health’s Prevention Change Packets and found that improvement
could be made in the following areas:
   •       Increasing percentage of Addison County adolescents receiving well-child visits
   •       Increasing adult BMI screening
   •       Improving adult type 2 diabetes control
   •       Improving pediatric weight assessment and control
   •       Improving practices for antibiotic prescribing
This spring we distributed a survey via survey monkey and received 594 responses from
Addison County residents. The top social and environmental challenges identified in our 2018
community survey were:
   •       Accessing affordable housing
   •       Lack of a livable wage and employment opportunities
   •       Accessing childcare
   •       Transportation
The top health challenges identified in our 2018 community survey were:
   •       Addressing substance use disorder
   •       Increasing access to mental health services

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Addison County Community Health Needs Assessment 2018 - Conducted by: Addison County Community Health Action Team (CHAT) Steering Committee
•       Addressing overweight and obesity
   •       Preventing and treating chronic conditions such as diabetes and heart disease
   •       Increasing access to healthcare services
The following pages will describe in detail the steps we’ve taken to garner input from community
members and partner organizations. This report concludes with an implementation plan on how
we will address many of the concerns and needs identified in this 2018 Community Health
Needs Assessment over the coming months and years.

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Addison County Community Health Needs Assessment 2018 - Conducted by: Addison County Community Health Action Team (CHAT) Steering Committee
1. Overview of our Community:
Addison County is located in the lower Champlain Valley of Vermont with Lake Champlain and
the Adirondacks to our west and the Green Mountains to our east. The unique landscape of
Addison County, the fertile farmlands of the Champlain Valley and the predominately wooded
settings near the foothills of the Green Mountains, provides a variety of lifestyles and a balanced
blend of light industry and farming. Addison County is rural and known for its dairy farming. It
has the most farm acreage in the state and leads the state in the value of agriculture products
sold (US Census Bureau, 2012). The County is home to three local newspapers, seven service
organizations and more than 100 faith communities. The major employers in the county include
Middlebury College, Porter Medical Center and UTC Aerospace Systems.
Addison County is bordered to the north by Chittenden County, Vermont’s most densely
populated county, which includes Vermont’s largest city, Burlington, and its surrounding suburbs.
The northern portion of Addison County is considered a commutable distance to Burlington so
residents have the option of traveling north for employment, healthcare, shopping and other
services. Addison County is bordered to the south by Rutland County. Rutland County is home
to Vermont’s second largest city, Rutland. Residents who live in the southern portion of Addison
County have the option of traveling to Rutland County for work, healthcare, etc. Addison County
is bordered to the east by Windsor, Orange and Washington Counties. For the eastern Addison
County communities of Hancock and Granville, accessing services within our county is
challenging particularly in winter as this typically requires traveling over mountains.
According to the US Census Bureau, the 2017 population estimate for Addison County is 36,776
which is approximately 5% of the state’s total population. According to population estimates,
Addison County had 0.1% decrease in population since the 2010 census. 92.7% of Addison
County residents are white non-Hispanic. Hispanic or Latino residents are Addison County’s
more prevalent minority population at 2.2%.
The percentage of Addison County residents who were uninsured was last measured in 2014 at
7.7%. However, the percentage of people living without health insurance is decreasing in
Addison County and across the state. One estimate shows that the percentage of Addison
County residents who are uninsured will drop to 3.28% by 2019. Vermont has one of the lowest
rates in the country of people living without health insurance. According to a 2017 article, the
statewide rate of uninsured has already dropped to 3.7%.
Addison County is similar to the state as a whole for unemployment and educational attainment.
Addison County has lower poverty and a higher median income than the state. Below is data
comparing Addison County to Vermont for unemployment, educational attainment, people living
in poverty and the median household income:

                                                            Addison County      Vermont
Unemployment Rate (April 2018)                              3%                  2.8%
% of Population with High School Diploma or Higher          92.5%               91.9%
% of Population with Bachelor’s Degree or Higher            35.8%               36.3%
% of Population under the federal poverty level             8.7%                11.9%
Median Household Income                                     $61,020             $56,104

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Addison County Community Health Needs Assessment 2018 - Conducted by: Addison County Community Health Action Team (CHAT) Steering Committee
In Addison County, 17.4% of the population is age 18 and under while 18.5% of the population
is age 65 years and older. This represents a significant shift in the age of the county’s
population. In our 2009 Community Health Needs Assessment, the population of Addison
County youth age 18 and under was 21% while the population of seniors age 65 and older was
13.3%. According to a June 29, 2017 Burlington Free Press article, Vermont is aging faster than
the nation as a whole. Vermont’s median age is 42.7 while the median age for all Americans is
38-years-old. Further, the number of people under the age of 20 is declining in Vermont while
the number of under- 20-year-olds is holding steady for the rest of the country.
Regarding education, many towns offer early education/preschool. However, it will be noted
later in this report that accessing childcare is a high priority for the 18-34-year-olds who
responded to our community survey. There are 23 public schools in Addison County serving
4,624 students. There are three school districts located within the county while the southern
most communities of Addison County (Leicester, Whiting, and Orwell) are part of school districts
that primarily serve Rutland County students. In addition to traditional secondary schools, the
Patricia A. Hannaford Career Center offers an integrated work and learning program to students
from the three Addison County school districts. Addison County is home to Middlebury College,
a prestigious liberal arts college, the Community College of Vermont and Northland Jobs Corps,
a residential and educational training program located in Vergennes for youth ages 16-24 years.
Population Centers:
Middlebury
Middlebury, the shire town of Addison County, was chartered in 1761 and was settled just after
the Revolutionary War. Today, the village is listed on the National Register of Historic Places
and is home to shops, businesses, churches and public buildings. Middlebury is the largest
community in the county with a population of 8,600. Middlebury is home to the Middlebury
College. Middlebury is also the hub for medical services in the county with the University of
Vermont Health Network Porter Medical Center, a critical access hospital, Helen Porter
Healthcare and Rehabilitation Center and many of the area’s medical provider offices.
Vergennes
Established in 1788, Vergennes is Vermont’s oldest incorporated city. Vergennes encompasses
1,200 acres of land that was carved from the three neighboring towns of Ferrisburgh, Panton
and Waltham. It is where Thomas Macdonough built and armed the fleet that would defeat the
British on Lake Champlain during the War of 1812. In the late 1990s Vergennes residents
launched a Main Street revitalization effort and formed the Friends of the Vergennes Opera
House to complete the restoration of the 1897 Opera House. Today, Vergennes is home to
2,600 residents and UTC Aerospace, one of the largest employers in the county.
Bristol
Bristol, known as the “Gateway to the Green Mountains,” was founded in 1762 and is currently
home to 3,900 residents. The town was originally known as Pocock, after a distinguished
English admiral. The name was changed to Bristol in 1789 but the community still celebrates its
heritage during the annual Pocock Rocks Street Fair. Bristol is also host to one of the largest
July 4th celebrations in the state. The Bristol Band has presented outdoor summer concerts on
the town green every Wednesday since shortly after the Civil War. Downtown Bristol is a
National Historic District with small shops and restaurants and a vibrant artist community.
Smaller Towns and Villages:

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Addison County Community Health Needs Assessment 2018 - Conducted by: Addison County Community Health Action Team (CHAT) Steering Committee
Approximately 60% of Addison County residents live outside the three population centers.
These outlying communities are rural with few local services. The communities are governed by
select boards and most have their own elementary school, fire department and town office.
There are small country and convenience stores/gas stations in some of these communities.
The large grocery stores are located in the population centers along with other shopping,
banking and healthcare services. Transportation is a significant issue in our county. Addison
County Transit Resources provides bus and volunteer driver services but these services are
somewhat limited to the outlying communities. Agencies such as the Addison County Parent
Child Center and Elderly Services provide transportation for their clients for specific purposes
but in general, transportation is a concern for those who do not drive and those without a
reliable vehicle.
There are ample opportunities for outdoor physical activity in Addison County including walking,
running, biking, swimming in lakes, streams and outdoor public pools and use of recreation
fields. However, there are concerns that the roads are dangerous for pedestrians and cyclists
due to fast moving traffic and narrow shoulders. The Walk-Bike Council of Addison County
formed in response to three cyclists deaths in the county several years ago and is working to
make walking and biking safer for everyone.

   2. Organizing to Address the Health and Wellbeing of Addison County
      Residents
Addison County Integrating Family Services:
Addison County’s human service organizations have a solid history of collaboration. For many
years, we had a strong regional partnership called the People of Addison County Together
(PACT). About 8 years ago, Addison County had the opportunity to become the pilot community
for a new state initiative called Integrating Family Services (IFS). IFS is a bundled payment
mechanism to the Counseling Service of Addison County and Addison County Parent Child
Center that strives to enhance services for our prenatal through 22-year-old population.
Addison County IFS adopted the triangle model, with its three risk levels (shown on page 8), to
organize our work. The Universal/Prevention level is what all children and families need to be
well including basic needs (housing, healthcare, transportation, food, clothing), quality
education, community connections, recreation, arts and leisure activities. The At-Risk level
provides additional supports for families who need some assistance. At-Risk level of supports
include respite care, mental health counseling, additional supports in schools, and job training.
High-Risk supports include one-on-one care, residential mental health and substance use
treatment, and programs that support individuals coming out of incarceration. The intent of this
model is to drive more interventions, services and programming down to the universal level (or
at least from the high-risk to at-risk level), so that all children and young adults have what they
need as soon as possible to be healthy, vibrant members of our community.

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Addison County Community Health Needs Assessment 2018 - Conducted by: Addison County Community Health Action Team (CHAT) Steering Committee
Resources including staff, $ and

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Addison County Building Bright Futures:
Building Bright Futures (BBF) is a statewide initiative dedicated to improving the well-being of
young children, age 0-8, and their families. BBF has three focus areas: building community
through 12 regional councils, making data available to the public and improving policies that
impact the lives of Vermont’s children and families.
In Addison County, because IFS and BBF have similar goals and an overlap in the populations
we serve, it made sense for these initiatives to merge. In 2014, Addison County BBF merged
with Addison County IFS to develop a combined strategic plan and a single steering committee.
Community Health Action Team:
Addison County’s Community Health Action Team (CHAT) formed in 2014. CHAT is a
community collaborative that promotes integration of health and human services to address
both medical and non-medical needs.
CHAT initially met monthly to discuss a variety of health and healthcare topics but meeting
participation started waning and CHAT members were struggling to find a focus. In 2016, CHAT
applied to be part of the Vermont Accountable Communities for Health Peer to Peer Learning
Lab. A committee of CHAT members participated in the Learning Lab sessions that gave us
opportunities to brainstorm how to strengthen CHAT meetings and prioritize our work.
In December 2016, we hosted a strategic planning meeting for CHAT with more than 50
community members in attendance. We had decided to adopt the Addison County IFS triangle
model and asked community members to prioritize needs for Addison County’s adult population
age 23 and older. The group generated many different ideas to assist Addison County adults
and then narrowed the priorities to the following:
    Universal level: family supports, programming & education
    At-Risk level: coordinated care
    High-Risk level: opioid treatment and housing

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Addison County Community Health Needs Assessment 2018 - Conducted by: Addison County Community Health Action Team (CHAT) Steering Committee
Over the winter of 2017, we created an organizational chart (shown below) that combined the
work of Addison County IFS, BBF and CHAT. We felt this was important to identify and agree
upon shared priorities, reduce duplicative meetings and improve communication. The proposed
organizational chart was put before the larger Addison County IFS, BBF and CHAT councils and
received approval. We also sought and received approval from the larger councils to fully
merge the Addison County IFS, BBF and CHAT steering committee. This meant that there
would be one organizing body focused on the health and well-being of Addison County
residents from prenatal through our oldest community members.

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Once we had approval to move forward with a combined IFS, BBF, CHAT steering committee,
we recruited members to better represent various sectors of our community. We agreed that
organizations, not individuals, will serve as members of the combined IFS, BBF, CHAT steering
committee. During the spring and summer of 2017, we recruited the following combined
steering committee member organizations:
    •       Vermont Blueprint for Health Middlebury
    •       Addison County Building Bright Futures
    •       Agency of Human Services

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•    Counseling Service of Addison County
   •    Department of Children and Families Middlebury District, Family Services
   •    Department of Children and Families Middlebury District, Economic Services
   •    Parent Child Center of Addison County
   •    Vermont Department of Health Middlebury District Office
   •    Addison County Community Trust
   •    Middlebury College
   •    University of Vermont Health Network Porter Medical Center
   •    One Care Vermont
   •    Elderly Services
   •    Mountain Health Center
   •    Addison County Home Health and Hospice
   •    United Way of Addison County
   •    Addison County Regional Planning Commission
   •    School Representative, Addison County’s three school districts have designated one
        person to participate on their behalf
In September 2018, the combined IFS, BBF, CHAT Steering Committee adopted a charter that
defines the steering committee membership, our role and how we govern ourselves. (Appendix
A: CHAT Charter)

   3. Review of Addison County Data
For the second year in a row, Addison County was ranked first in health outcomes among
Vermont’s 14 counties by the Robert Wood Johnson Foundation County Health Rankings.
While we have some good health outcomes there is still have room for improvement. According
to the 2015-2016 Behavioral Risk Factor Surveillance System (BRFSS) data for the Middlebury
Health District, 26% of Addison County adults have been diagnosed with hypertension and 34%
have high cholesterol. 23% of Addison County adults have been diagnosed with depressive
disorder and 7% did not visit the doctor in the last year due to cost.
Additional BRFSS data for the Middlebury Health District and Vermont is provided below:
Health Status Indicators:

                                                             Addison County    Vermont
Have personal health care provider                           87%               88%
Did not visit doctor due to cost, in last year               7%                8%
Poor physical health                                         10%               11%
Poor mental health                                           11%               12%

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Disabled                                                   20%               23%

Risk Factors:

                                                           Addison County    Vermont
Adverse Childhood Experiences (ACEs), four or more         12%               14%
Binge drinking, in last month                              16%               18%
Heavy drinking, in last month                              8%                9%
Marijuana use, in last month                               8%                12%
Prescription drug misuse, ever                             7%                7%
Smoke cigarettes, currently                                14%               18%
No leisure time physical activity                          20%               18%

Disease Prevalence:

                                                           Addison County    Vermont
Arthritis, ever diagnosed                                  27%               28%
High cholesterol, ever diagnosed                           34%               34%
Depressive Disorder, ever diagnosed                        23%               22%
Diabetes, ever diagnosed                                   10%               8%
Hypertension, ever diagnosed                               26%               25%
Overweight, ages 20+                                       32%               34%
Obese, ages 20+                                            31%               28%

Annual Data Meeting:
As outlined in the CHAT Charter, we decided that the larger councils would meet twice a year
meaning there are two large meetings for BBF, two meetings for IFS and two meetings for
CHAT. We also decided it would be important to do an annual review of Addison County data to
get a yearly status update on the health and wellbeing of our community.
In December 2017, we hosted our first annual Addison County data meeting. More than 40
people attended the meeting and were asked to bring one piece of data that influences their
work. We presented data on Addison County residents across the lifespan including information
from IFS, One Care Vermont, Blueprint for Health, Vermont Department of Health and Elderly

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Services. We then broke into small groups based on our three risk levels (universal/prevention,
at-risk, high-risk) to dig deeper into the data. (Notes from the data meeting breakout sessions
are included in Appendix B.)
The most significant discovery from our data review was a lack of resilience among children in
Addison County. Two of our school districts and the Counseling Service of Addison County
conduct regular screening of school-age children and found a concerning number of students
with high anxiety, low optimism and low resilience. During the data meeting small group
discussions, the universal/prevention group focused their entire conversation on the issue of
building resilience and how to move forward with a community-wide resilience campaign.
Prevention Change Packets:
The Prevention Change Packets were developed by the Vermont Department of Health and
include evidence-based strategies for health measures identified by Vermont’s Accountable
Care Organizations. The intent of the Prevention Change Packets is to help health care
providers address the social determinants of health and to increase their focus on prevention.
According to Healthy People 2020, social determinants of health are conditions in the
environments in which people are born, live, learn, work, play, and age that affect a wide range
of health, functioning, and quality-of-life outcomes and risks.
We spent time at several combined steering committee meetings during the winter of 2018
reviewing and discussing the Prevention Change Packets. Vermont Department of Health
Middlebury staff with assistance from a health department statistician, reviewed health
department and Blueprint for Health data to identify priorities areas for Addison County from the
Prevention Change Packet health measures.
We acknowledge that there are some limitations with our data and that further investigation
about how local health care providers may already be addressing these issues is needed.
However, based on our Addison County data, the following health measures were deemed as
areas for improvement:
   •    Increasing percentage of Addison County adolescents receiving well-child visits
   •    Increasing adult BMI screening
   •    Improving adult type 2 diabetes control
   •    Improving pediatric weight assessment and control
   •    Improving practices for antibiotic prescribing
(See Appendix C for identified Prevention Change Packet health measures and Addison County
data.)
As a follow up to the Prevention Change Packets data review, the Vermont Department of
Health Middlebury office is planning an Addison County nutrition resources event for fall 2018.
This is a first step to address pediatric and adult weight screening and type 2 diabetes control.
Our plan is to bring together local nutrition resources including the Blueprint Community Health
Team Dietitians, Expanded Food and Nutrition Education Program (EFNEP), and coordinators
of gleaning programs and community cooking classes to share their resources and referral
information with health, education and human service practitioners.

   4. Community Survey Findings

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During the spring of 2018, we launched a community survey via Survey Monkey to assess the
top health and social needs of our community. 594 Addison County residents completed the
survey and we received at least one response from residents in every town in the county. While
we feel this was an excellent response to our survey, it is important to acknowledge the
limitations of our data. 158 respondents did not provide their age but of those who did, a
majority (62%) were women over the age of 50. In addition, 176 respondents did not provide
their income but of the respondents who did, a majority (51%) earned more than $50,000 per
year. We are concerned that we did not hear from many younger residents, lower-income
residents or men of all ages. We’ll share in the implementation section of this report how we
plan to dig deeper into the community survey data at our next annual data meeting and hope to
develop a plan to garner additional input from these specific populations.
Despite some limitations with our survey data, we were able to glean useful information from the
responses. In general, the survey responses confirmed community challenges that had
previously been identified by our health, education and human service partners at our
December 2016 CHAT strategic planning session. Survey respondents identified affordable
housing as the most concerning social challenge in our community and substance use disorder
was identified by survey respondents as the most concerning health issue.
Survey respondents selected the following social and environmental challenges as the most
concerning for our community:

Top 5 Challenges                              # of Respondents who     % of Respondents who
                                              selected Challenge*      selected Challenge*
Affordable housing                            308                      52%
Lack of a livable wage                        249                      42%
Lack of employment opportunities              191                      32%
Childcare                                     169                      28%
Transportation                                152                      26%

Survey respondents selected the following health challenges as the most concerning for our
community:

Top 5 Challenges                              # of Respondents who     % of Respondents who
                                              selected Challenge*      selected Challenge*
Substance use disorder (drug and alcohol      399                      67%
misuse)
Access to mental health services              310                      52%
Overweight/obesity                            275                      46%
Chronic disease (diabetes, heart disease,     183                      31%
high blood pressure, high cholesterol,
stroke)
Access to healthcare services                 172                      29%

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*Note: Respondents were asked to pick up to 5 challenges which why the number of responses equals
more than the number of surveys received and why the percentage equals more than 100%

We also asked survey respondents about challenges they or family members have experienced
in the last year. Survey respondents or their family members had experienced an average of
2.1 social/environmental and health challenges in the last year.
Survey respondents or their family members have experienced the following social and
environmental challenges in the last year:

Challenges Experienced                         # of Respondents who      % of Respondents who
                                               Experienced Challenge     Experienced Challenge
Lack of a livable wage                         142                       24%
Affordable housing                             122                       21%
Lack of employment opportunities               108                       18%
Street safety (crosswalks, shoulders, bike     92                        16%
lanes, traffic control)
Climate change                                 90                        15%

Survey respondents or their family members have experienced the following health challenges
in the last year:

Challenges Experienced                         # of Respondents who      % of Respondents who
                                               Experienced Challenge     Experienced Challenge
Overweight/obesity                             202                       34%
Chronic disease (diabetes, heart disease,      168                       28%
high blood pressure, high cholesterol,
stroke)
Aging problems                                 129                       21%
Physical activity                              114                       19%
Access to mental health                        97                        16%

We then asked survey respondents to rank social/environmental and health issues in order of
importance. Affordable housing and mental health were ranked as the most important issues for
our community. However, the average for the rankings of the important social/environmental
and health issues were very close.
While not statistically significant because the number of respondents was low for younger age
groups, it is interesting to note that our youngest respondents, the 18-24-year-old age group,
reported experiencing twice as many (an average of 4.3) social and environmental challenges.

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For this 18-24-year-old group, affordable housing was identified as the most important issue.
Again, while not statistically significant, childcare was identified as the most important issue for
18-34-year-old respondents.
(Additional summary charts of our community survey data are included in Appendix D and the
survey questions are included in Appendix E.)

   5. Implementation Plan
Addressing Community Survey Results:
Addison County’s health and human service partners are working to address three (affordable
housing, childcare and transportation) of the top five social and environmental challenges
identified by community survey respondents.
Housing: See housing section of the implementation plan on page 16.
Childcare: Addison County Building Bright Futures hosted in a childcare summit in October
2017 to discuss ways to increase access to high quality early education in the county. BBF is
continuing to follow up on action items from the summit. In the meantime, Mary Johnson
Children’s Center just announced that they received grant funding to increase the number of
infant childcare slots in the county.
Transportation: Addison County Transit Resources is a member of CHAT. ACTR staff also
attended a combined steering committee meeting this spring to brainstorm strategies to
increase the number of riders who receive rides through Medicaid. Addressing transportation
needs is an ongoing conversation with health, human service and education partners.
Addison County health and human service partners are working to address all five of the top
health concerns identified by community survey respondents:
Substance Use Disorder: See Treatment for Substance Use Disorder on page 17.
Access to mental health supports: Since implementing IFS, Counseling Service of Addison
County has been able to serve more children and young adults and the number of crisis calls
CSAC receives has decreased. The Blueprint for Health has imbedded CSAC mental health
clinicians in local healthcare provider offices making it easier for providers to make mental
health referrals and for patients to access mental health services. Unfortunately, there is a still a
waiting list for adult mental health services at CSAC. CSAC has had job openings for mental
health clinicians but has struggled to recruit qualified candidates.
Overweight/obesity and chronic disease: The Vermont Department of Health Middlebury Office
received a grant last year to fund activities related to the 3-4-50 campaign. 3-4-50 stands for
three behaviors (tobacco use, lack of physical activity and poor nutrition) that lead to four
chronic conditions (cancer, heart disease, lung disease and diabetes) that result in 50% of the
deaths in Vermont. Through this funding, VDH Middlebury funded a winter passport to get kids
and families more physically active in the winter. VDH also funded a vegetable prescription
program at Mountain Health Center in Bristol. Mountain Health staff identified and recruited pre-
diabetic patients to receive a free CSA vegetable share last fall and again this spring. VDH
Middlebury partnered with Middlebury Union High School Alternative Education students to build
raised garden beds at the homes of local WIC participants. (WIC stands for Special
Supplemental Nutrition Program for Women, Infants and Children.) Finally, the grant purchased
sports equipment for May Johnson Children’s Center’s Rural Fun Delivery Program. Rural Fun
Delivery is a summer program that provides lunches and fun activities for children in Starksboro.

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University of Vermont Health Network Porter Medical Center will be partnering with Rise VT in
Addison County. Rise VT was developed in Franklin County and is an evidenced-based
program focused on reducing BMIs. The Blueprint for Health provides self-management
programs in Addison County to help those who have been diagnosed with a chronic illness learn
more about how to care for themselves and improve their health.
Access to healthcare services: To address healthcare access, University of Vermont Health
Network Porter Medical Center opened Porter ExpressCare last June. Porter ExpressCare is a
walk-in care clinic for adults and children over age 2 with minor illnesses or injuries who are
unable to get an immediate appointment with their primary care provider.
Addressing CHAT and Prevention Change Packet Priorities:
Community Resilience Campaign: Following the CHAT data meeting, we continued
conversations about developing a resilience campaign. In March and June 2018, we hosted
IFS Council meetings to help prioritize campaign activities. Vermont Department of Health
Middlebury District Office hosted a series of brown bag lunches on resilience. The Addison
County Parent Child Center provided training to their staff on resilience. Counseling Service of
Addison (CSAC) held a staff retreat this spring focused on resilience building. Finally, CSAC
also hosted a May 2018 meeting of local Executive Directors and their Board Chairs to share
more information about the work of CHAT and our proposed resilience campaign.
CSAC has hired a local marketing contractor to help us develop our brand and tag lines for the
resilience campaign. We will continue to meet over the summer to flesh out campaign
components and plan to launch a county-wide resilience campaign in the fall of 2018.
Nutrition resources event: As previously stated, the Vermont Department of Health Middlebury
office is planning to host a nutrition resources event in this fall so partners can learn more about
the nutrition resources in Addison County.
Coordinated Care: Blueprint for Health Middlebury staff are facilitating several initiatives to
improve care coordination and communication among healthcare and human service providers.
The Complex Care Coordination team includes staff from Porter Medical Center, local
healthcare provider offices, CSAC, Addison County Home Health and Hospice, Bayada Home
Health Care and One Care Vermont. The team meets monthly to discuss the needs of and
resources for patients with complex medical needs. The Women’s Health Initiative is providing
enhanced health and psychosocial screenings and referrals, comprehensive family planning
counseling and access to long acting reversible contraception. The Women’s Health Initiative is
being implemented in Addison County at Porter’s Women’s Health Center and the Planned
Parenthood Middlebury Health Center. Finally, local Medication Assisted Treatment (MAT)
providers are working with Porter’s Women’s Health Center, local pediatricians and human
service organizations to provide substance use treatment to pregnant women in Addison
County. This initiative is just starting so the group is working on consent forms and determining
the best modes of communication.
Housing: As soon as our combined steering committee started meeting regularly, the issue of
housing became a primary topic. According to data from the Vermont Agency of Human
Services, the current vacancy rate for housing in Addison County is 0.2%. A typical housing
market is considered balanced and healthy when vacancies remain between 4% and 6%. 45%
of Addison County renter households spend more than 30% of their incomes on rent and 22% of
Addison County renters pay more than half of their incomes toward rent. Approximately 100
individuals in Addison County are homeless on any given night. Finally, it is estimated that

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Addison County needs about 1,200 additional rental units to serve households earning less than
the area median income.
We focused the November 2017 CHAT Council meeting on housing issues. Following the
November meeting, Addison County Regional Planning Commission (ACRPC) developed and
disseminated a survey to area non-profits to assess local housing assets and potential
resources that could be dedicated to addressing housing needs in the county. ACRPC led a
housing subcommittee of CHAT and by the spring of 2018, the subcommittee developed a four-
component proposal that focuses on creating more middle-income workforce housing, lower-
income workforce housing, permanent supportive housing and dispersed elderly single room
occupancy units. We then created three committees to take on these four housing initiatives.
(We combined the lower-income workforce housing and permanent supportive housing into one
committee since there was so much overlap in the organizations involved in these projects.)
The three committees are now working on projects and seeking grant funds to help move these
housing initiatives forward. Vermont HomeShare will present at our September 2018 combined
steering committee meeting so we can learn more about their work in housing older Vermonters.
These projects won’t solve all of the housing needs in Addison County but we feel this is a good
start. (Appendix F: Housing Proposal)
Treatment for Substance Use Disorder: The Addison County Substance Use and Prevention
Committee was formed in 2014. The initial focus of the group was to address the lack of
treatment providers in Addison County for opioid misuse. In 2014, there were no healthcare
providers providing mediation assisted treatment. Thanks to the efforts of Porter Medical
Center, CSAC, Mountain Health Center and the providers themselves, there are now seven
Addison County healthcare providers providing medication assisted treatment along with
counseling to individuals struggling with substance use disorder.
More recently, the Addison County Substance Use and Prevention Committee has shifted its
focus to prevention and promotion of recovery resources including programming at the Turning
Point Center of Addison County. The Addison County Substance Use and Prevention
Committee worked with the Regional Prevention Partnership to host a successful community
book read of The Seventh Wish with a presentation by the author, Kate Messner. The
Committee has developed a website, www.addictionhelpvt.com, and provides school and
community presentations. The Substance Use and Prevention Committee will be sharing
resources at upcoming community events including Vergennes Day and the Bristol Harvest
Festival.
Finally, the United Way of Addison County has developed a very successful program called
HELP. HELP stands for Heroin Epidemic Learning Program. HELP teaches high school
students filmmaking skills and provides information about opioid use disorder. Volunteer
experts in filmmaking as well as law enforcement, first responders and individuals impacted by
substance use disorder teach students about both filmmaking and the impacts of drug use.
Students use their new knowledge to create public service announcements (PSAs). The
program culminates in a public screening of the PSAs and awards for the best student-made
films. HELP has become well-known in the state and other regions are asking to replicate the
program in their communities.
Getting Additional Input from the Community:
As previously stated, we are concerned that we did not receive many community survey
responses from younger residents, lower-income residents or men of all ages. We will spend
time at our next annual CHAT data meeting reviewing our survey data and brainstorming ways

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to get additional information about the health needs of these specific populations and what
additional action steps might be required to address priority areas of these groups.

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References
Addiction Help Vermont: http://addictionhelpvt.com/
American Fact Finder, Addison County, Vermont: https://factfinder.census.gov/faces/nav/jsf/
pages/community_facts.xhtml?src=bkmk
Art Wolf, Burlington Free Press, (June 29, 2017): https://www.burlingtonfreepress.com/story/
money/2017/06/29/vermont-population-aging-faster-than-nation/435238001/
Bureau of Labor Statistics, Unemployment Rate for Addison County and Vermont (March 2018),
https://www.bls.gov/cps/cps_htgm.htm
Discover Bristol, Vermont: http://discoverbristolvt.com/
Healthy People 2020, Social Determinants of Health: https://www.healthypeople.gov/2020/
topics-objectives/topic/social-determinants-of-health
United Way of Addison County, HELP (Heroin Epidemic Learning Program): https://
www.unitedwayaddisoncounty.org/heroin
Improving Population Health Outcomes, Prevention Change Packets: http://
www.healthvermont.gov/sites/default/files/documents/pdf/
ADM_Prevention_Change_Packet%20_Combined.pdf
Mattie Quinn, Governing, (September 13, 2017): http://www.governing.com/topics/health-
human-services/gov-uninsured-rate-census-2016-states.html
Middlebury Health District 2015-2016 Behavioral Risk Factor Surveillance System (BRFSS)
data, http://www.healthvermont.gov/sites/default/files/documents/pdf/olh_profile_middlebury.pdf
Open Data Network, Percent Uninsured: Addison County, https://www.opendatanetwork.com/
entity/0500000US50001/Addison_County_VT/health.health_insurance.pctui?
year=2014&age=18%20to%2064&race=All%20races&sex=Both%20sexes&income=All%20inco
me%20levels
Percentage of People Living at or below the Federal Poverty Level, Vermont: https://
embed.resultsscorecard.com/Indicator/Embed?id=68540&navigationCount=1
Public School Review: https://www.publicschoolreview.com/vermont/addison-county
Robert Wood Johnson Foundation, 2018 County Health Rankings, Addison County, Vermont:
http://www.countyhealthrankings.org/app/vermont/2018/rankings/addison/county/outcomes/
overall/snapshot
US Census Bureau, Census of Agriculture County Profile, (2012): https://
www.agcensus.usda.gov/Publications/2012/Online_Resources/County_Profiles/Vermont/
cp50001.pdf
US Census Bureau Quick Facts Addison County, (2017): https://www.census.gov/quickfacts/
fact/table/addisoncountyvermont/AGE135216#viewtop
US Census Bureau Quick Facts Vermont, (2017): https://www.census.gov/quickfacts/fact/table/
vt/PST045217
Vergennes Partnership, History of Vergennes: http://www.vergennesdowntown.org/

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Walk-Bike Council of Addison County: https://www.walkbikeaddison.org/

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Appendix A
Addison County Community Health Action Team (CHAT)
                                       CHARTER
BACKGROUND & HISTORY:
Addison County’s Community Health Action Team (CHAT) formed in 2014. CHAT initially met
monthly to discuss a variety of health and healthcare topics as part of the Community
Collaborative (CC) that originated from the Vermont Health Care Improvement Project (VHIP).
CHAT is a community collaborative that promotes the cohesive integration of health and
human services addressing both the medical and non-medical needs that impact measurement
results and outcomes, including social, economic and behavioral factors. The structure, with
administrative support locally from the Blueprint and the ACOs will result in more effective
health services as measured by improved results in quality, health status, utilization and
experience of care.
In 2016, CHAT applied to be part of the Vermont Accountable Communities for Health (ACH)
Peer to Peer Learning Lab. A committee of CHAT members participated in the ACH Learning
Lab sessions, which gave the CHAT representatives opportunities to brainstorm how to
strengthen CHAT meetings and prioritize our work going forward. We decided to build on the
model used for Addison County’s Integrating Family Services (IFS) initiative which strives to
enhance services for our prenatal through age 22-year-old population (model below).
Addison County’s IFS uses a triangle model with universal/prevention on the bottom, at-risk in
the middle and high-risk at the top. The intent is to drive more interventions, services, and
programming down to the universal level (or at least from high-risk to at-risk), so that all
children and young adults get what they need as soon as possible to be healthy, vibrant
members of community.

                                   High
                                   Risk

                                 At-Risk

                               Universal
                              Prevention

In December 2016, we hosted a strategic planning meeting for CHAT with more than 50
community members in attendance. Using the IFS model, we asked community members to
prioritize the needs for the Addison County adult population age 23 and older.

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We discussed many different topics during our December 2016 meeting and then narrowed our
priorities to the following:
For the Universal/Prevention level, we prioritized:
   •    Mental health/empowerment
   •    Parenting supports/family services
   •    Community-wide programming and education
For the At-Risk level, we prioritized:
   •    Care coordination and communication
   •    Person-centered approaches
   •    Screening and proactive treatment of chronic diseases
For the High-Risk level, we prioritized:
   •    Housing
   •    Medication-assisted treatment for opioid addiction
   •    Access to care
Since the December 2016 CHAT meeting, we have formed new committees or have engaged
existing committees to work on these priority areas.
MERGING BBF, IFS, AND CHAT:
In 2014, Addison County Building Bright Futures (BBF) merged with Addison County IFS to
create one strategic plan with a single steering committee. Given that all of these groups are
focused on improving the health and wellbeing of Addison County residents, it made sense to
combine IFS and BBF with CHAT.
Over the winter of 2017, we created an organizational chart that combined the work of IFS,
BBF and CHAT (organizational chart below). We felt this was important to identify and agree
upon shared priorities, reduce duplicative meetings, and improve communication. The
proposed organizational chart was put before the larger BBF/IFS and CHAT councils and
received approval.

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ROLES OF THE STEERING COMMITTEE:
The combined steering committee will:
   •    Establish agendas for our larger community meetings
   •    Facilitate communication between existing committees and teams
   •    Plan and host interagency trainings
   •    Share and review data
   •    Seek input from larger CHAT, IFS and BBF meeting participants to set shared regional
        priorities
   •    Make funding decisions and oversee management of funds
   •    Identify individuals to connect with the statewide ACH efforts, including attending
        meetings and sharing information to and from the statewide groups
MEETINGS:
As reflected in the organizational chart, we are organizing ourselves by intervention level
(universal/prevention, at-risk, high-risk) yet, the three initiatives (BBF, IFS and CHAT) each

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has their own membership/partners and reporting requirements. Therefore, we decided each
group should meet twice per year with an additional meeting focused on reviewing and
discussing local data.
Large Group meeting schedule:
   •    IFS will meet in September and March
   •    BBF will meet in October and April
   •    CHAT will meet in November and May
   •    The annual data meeting will take place in December
As of the drafting of this charter, the combined steering committee has agreed to meet on the
4th Thursday of the month from 9:00 – 11:00am.
The IFS/BBF combined steering committee will continue to meet monthly on the 2nd Monday
of the month from 10:00am – 11:30am to address the programmatic and systems needs of
children and young adults up to age 22-years. Addison Building Bright Futures will act as a
sub-committee of the greater IFS/BBF council, and will meet monthly (2nd Friday of the month
from 9:00-12:00) to focus on early childhood related systems issues of the IFS/BBF strategic
plan.
Finally, because we will not have healthcare represented at the IFS/BBF steering committee
meetings due to scheduling conflicts, we have agreed that all healthcare related issues for
children and young adults will be tabled and discussed at the combined steering committee
meetings.
FACILITATION:
Planning and facilitation of the large group meetings will be a team effort of members from
the combined steering committee. Outside facilitation can be utilized as appropriate
particularly if there are challenging decisions to work through.
The monthly combined steering committee meetings will be planned and facilitated by Moira
Cook.
Cheryl Huntley and Dana Anderson will continue to facilitate the IFS and BBF steering
committee meetings.
STEERING COMMITTEE MEMBERSHIP:
Background: The initial steering committee members were those who participated in the
ACH Peer-to-Peer Learning Lab. Once we realized it made sense to combine the IFS/BBF
steering committee with the CHAT steering committee, the IFS/BBF steering committee were
included in the combined steering committee. However, after we set our priorities and
developed the organizational chart, we knew the steering committee membership had to be
expanded to better represent various sectors of our community.
We agree that organizations/businesses will serve as members of the CHAT steering
committee, not the individual staff members listed below. When there is staff turnover, the
organization will remain on the steering committee and must assign a new designee to serve
on the combined steering committee. There will be an annual review of this charter and the
composition of the combined steering committee. (See page 8.)

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The proposed combined steering committee members are:
   •    Vermont Blueprint for Health Middlebury Staff – Susan Bruce, Project Manager
   •    Building Bright Futures – vacant, Regional Coordinator for Addison and Rutland
        Counties
   •    Agency of Human Services – Adam Sancic, Field Director
   •    Counseling Service of Addison County – Cheryl Huntley, Operations Director
   •    Department of Children and Families, Family Services – Andrea Grimm, District
        Director
   •    Department of Children and Families, Economic Services - Robyn Stattel, District
        Director
   •    Parent Child Center of Addison County – Donna Bailey, Co-Director
   •    Vermont Department of Health – Moira Cook, District Director
   •    Addison County Community Trust – Elise Shanbacker, Executive Director
   •    Middlebury College – Dave Donahue, Special Assistant to the President and Community
        Relations
   •    Porter Hospital – Carrie Wulfman, Chief Medical Officer
   •    One Care – Trevor Hanbridge, ACO Clinical Consultant
   •    Elderly Services – Jen Stewart, Licensed Clinical Social Worker
   •    Mountain Health Center – Martha Halnon, Chief Executive Officer
   •    Addison County Home Health and Hospice – Tim Brownell, Executive Director
   •    United Way of Addison County – Kate McGowan, Executive Director
   •    Addison County Regional Planning Commission – Adam Lougee, Executive Director, or
        Claire Tebbs, Senior Planner
   •    School Representative, Addison County’s three school districts have designated one
        person to participate on their behalf – Susan Bruhl, Special Education Coordinator,
        Addison Northeast Supervisory Union
   •    Business Community Representative – to be determined

OPERATING PRINCIPLES:
The combined steering committee will utilize the following operating principles to guide their
work:
Collaboration: Promote cross-sector participation throughout Addison County.
Equality: All combined steering committee members have equal standing regardless of their
organizational size and resources.

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Consensus: Decisions are made by consensus. We work through an issue until everyone can
support it.
Shared Learning: Focus on exploring and sharing opportunities for innovation.
DECISION MAKING:
   1. We aim for consensus.
        The combined steering committee aims to reach consensus on key decisions.
        Consensus in this context does not necessarily mean 100% agreement on all parts of
        every issue, but rather that all members review a decision in its entirety and can say
        “I can live with that.”

        The combined steering committee will work to understand and integrate perspectives
        until a solution is identified that is acceptable to everyone.

        We use a “thumbs up/thumbs down” signal as a way of gauging members’ positions:
           •   Thumbs up – supports the decision
           •   Thumbs middle – neutral, can live with the decision
           •   Thumbs down – deal breaker, suspends the decision until further discussion
        In the event of a thumbs down vote, we attempt to resolve the issue through further
        discussion in a reasonable amount of time. In the event that’s not doable, a sub-team
        of the council will convene separately and come back with recommendations.
   2. We act as team players.
      As combined steering committee members, we acknowledge and are explicit about our
      organizational or sector-specific self-interests but also participate in service to the
      collective, common agenda. As such, we are conscientious about invoking our veto
      power (thumbs down vote) and ask ourselves first, “is this issue or decision
      fundamental to my participation in the combined steering committee?” We also
      expect combined steering committee members to actively reach out to clients,
      colleagues, and community partners to help inform the steering committee’s
      decisions.

   3. A quorum is required.
      A quorum of the majority of combined steering committee members is required for a
      decision to be considered valid. We will solicit input from any organization/business
      or interested parties, with adequate warning, prior to voting. Any interested party
      can participate in a combined steering committee meeting however, only the members
      listed above, their designee, or their dually appointed successor can vote.

   4. One must be present to win.
      Members or their designees must be present to vote on decisions. Each organization/
      business has one vote only. If more than one staff member from an organization/
      business is present, they must determine who will vote on behalf of their organization.

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If a member is unable to attend a combined steering committee meeting, they agree
        to communicate their views to the entire steering committee via email in advance of
        the meeting. However, combined steering committee members must make every effort
        to regularly attend meetings or send a designee.

   5. Once it’s done, it’s done.
      We revisit previous decisions by the combined steering committee only if the members
      collectively agree to re-open and issue.
EXECUTIVE COMMITTEE:
The Executive Committee shall consist of 4-7 members of the combined steering committee
to set agendas for the monthly steering committee meetings and for the larger community
meetings. The Executive Committee will also develop recommendations for consideration by
the combined steering committee. While the Executive Committee prepares important
decisions for the combined steering committee, it does not have the authority to make
binding decisions on behalf of the combined steering committee unless so authorized to do so
by the combined steering committee.
AD HOC WORK GROUPS:
Ad hoc work groups will be created as needed to provide temporary assistance on issues
outside the combined steering committee’s or executive committee’s roles when additional
time is needed to develop work products.
CONFLICT OF INTEREST POLICY:
   1. Purpose
        The purpose of this policy is to help inform the combined steering committee about
        what constitutes a conflict of interest, and assist the combined steering committee in
        identifying and disclosing actual and potential conflicts. The combined steering
        committee is a collaborative of interested parties and it is acknowledged that
        combined steering committee members will have organizational and/or sector-specific
        self-interests. Conflicts of interests happen all the time. In fact, they are inevitable.
        The key therefore is not to try to avoid all possible conflict-of-interest situations,
        which would be impossible, rather the combined steering committee needs to identify
        and follow a process for handling them effectively.

   2. What is a real or potential conflict of interest?
        A real conflict of interest is present when a combined steering committee member’s
        stake in a decision is such that it clearly reduces the likelihood that the combined
        steering committee member’s influence can be exercised impartially in the best
        interest of this collaborative. A potential conflict of interest exists when there is
        either the appearance of a real conflict of interest, even if a real conflict doesn’t
        exist, or the decision contemplated by the combined steering committee could
        possibly involve a real conflict of interest for one or more combined steering
        committee members.

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Of particular concern are personal conflicts of interest. A personal conflict of interest
     exists when a combined steering committee is in a position to influence a decision that
     may result in personal gain, or gain for a relative as a result of the collaborative’ s
     business dealings. For this this policy, a relative is any person is related by blood or
     marriage or domestic partnership.

     In the case of this collaborative, special attention needs to be paid to situations where
     organizational conflicts of interest could result in personal gain. Such conflicts are to
     be considered as equivalent to personal conflicts of interest and should be handled as
     such.

3. How to manage a real or potential conflict of interest?
     A combined steering committee member who has a real or potential conflict of
     interest must do the following:

     A. Duty to Disclose
          Each combined steering committee member shall disclose all material facts
          regarding his or her interest in the decision under consideration promptly upon
          learning of the proposed decision. It will not be necessary to excuse oneself from
          participating in the related discussions or in the voting process as long as the
          conflict is not a personal conflict or an organizational conflict that could result in
          personal gain and has not been disclosed. In the case of a personal conflict or an
          organizational conflict that could result in personal gain, combined steering
          committee members will excuse themselves from the voting process.

     B.    Determining Whether a Conflict of Interest Exists
          If necessary, the combined steering committee may determine if a personal
          conflict of interest or an organizational conflict that could result in a personal gain
          for a combined steering committee member. The combined steering committee
          member(s) and any other interested person(s) involved in with the decision need
          not be present during the combined steering committee’s discussion or
          determination of whether a personal conflict of interest exists or an organizational
          conflict that could result in personal gain.

     C. Procedures for Addressing a Conflict of Interest
          1.    The combined steering committee may ask questions of and receive
               presentation(s) from the combined steering committee member(s) and any
               other interested person(s) that have a personal conflict of interest, but shall
               vote on the decision in their absence.
          2. The combined steering committee shall ascertain that all material facts
             regarding the decision and the insider’s conflict of interest have been disclosed
             to the combined steering committee.

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